Good Samaritan Nursing Home Operator, LLC

Based on observation, medical record review, and interview, it was determined the facility staff failed to provide adequate care to prevent complications from hand contractures. This was evident for 1 (#83) of 3 residents reviewed for limited range of motion (ROM) during a recertification/complaint survey. The findings include: A contracture is an abnormal shortening of muscle tissue causing the muscle to be resistant to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to the palm of the hand caused by the pressure of fingers/fingernails pressing into the palm of the hand. Observation of Resident #83 on 4/25/2025 at 9:15 AM revealed that the resident's left hand was contracted. The resident's fingers were bent inwards and nails pressing into the palm of the resident's hand. When instructed to open their left palm, Resident #83 stated s/he could not do so. The resident did not have a protective device (palm protector/splint) to prevent pressure to their palm, and none was visible in their room. The observation was brought to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, and interview, it was determined the facility staff failed to 1) label oxygen tubing and humidifier bottle when changed, and 2) equip a resident with an incentive spirometer to address their respiratory needs per physicians order. This was evident for 2 (#45, #67) of 3 residents reviewed for respiratory care during a recertification/complaint survey. The findings include: Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider. An incentive spirometer is a simple, plastic medical device that exercises your lungs. Your healthcare provider may recommend that you use an incentive spirometer after an illness, surgery or an injury to your chest or abdomen. An incentive spirometer helps prevent lung infections by expanding your lungs, strengthening your lungs, keeping your lungs inflated and clearing mucus and other secretions. You may have low oxygen levels after surgery or a serious illness, and an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews with residents and staff and medical record reviews, it was determined the facility failed to ensure that residents were given pain medications timely and consistent with professional standards of practice. This was evident for 2 ( #237, #37) of 4 residents reviewed for pain management during a recertification/complaint survey. The findings include: 1) On 4/24/25 at 11:10 AM during the initial tour of the facility, Resident #237 told the surveyor that s/he was not sure if their pain medication was ordered as needed or scheduled because they were not getting it on time. Review of the Physicians' order on 4/28/25 at 11:59 AM had orders written as: 4/19/25: Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug* Give 2 tablet by mouth at bedtime for Back pain. 4/20/25: Acetaminophen Oral Tablet 500 MG (Acetaminophen), Give 1 tablet by mouth at bedtime for pain Do not exceed 3 gm in 24 hours. On 4/28/25 at 1:50 PM a review of the facilities medication administration policy had under #5 that medication passes must be started no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview with residents, review of medical records, and interviews with facility staff, it was determined that the facility staff failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #67) of 47 residents reviewed during the facility's recertification/complaint survey. The findings include: Resident #67 was interviewed on 4/24/25 at 10:06 AM. During the interview s/he stated s/he was missing some teeth, and it was causing him/her pain and discomfort. Resident #67 opened his/her mouth to show the surveyor. The surveyor observed several missing and/or jagged teeth. Additionally, s/he stated that x-rays were taken, but s/he had not heard anything after that and was waiting for a follow up appointment with the dentist. On 4/29/25 at 8:05 AM review of Resident #67's medical record revealed the following dental notes: - 2/10/25 Dentist Note: The Tooth Grid of the dental note revealed the resident had 9 missing teeth, 2 non-restorable teeth, 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a complaint, record review, resident and staff interviews, it was determined the facility failed to develop, prepare, and distribute menus that reflect a resident's nutritional wishes. This was evident for 1 (#37) of 2 residents reviewed for food during a recertification/complaint survey. The findings include: In an interview with Resident #37 on 4/24/2025 at 9:05 AM, the Resident stated that the food served did not match what was on the meal ticket. Resident #37 stated that s/he was allergic to pork but they served her/him pork sausage and bacon. Resident #37 further stated that s/he did not eat corn because of a medical condition but they served her/him corn even though the meal ticket indicated no pork and no corn. Review of Resident #37's clinical records on 4/29/2025 at 10:42 AM revealed the resident had allergies that include but not limited to Corn and Pork. An interview was conducted with the Registered Dietitian (RD #7) on 5/2/2025 at 9:13 AM: Regarding Resident #37's food concerns, RD #7 stated they were aware that the resident was served food items (pork and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews with facility staff and review of medical records, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of a resident's discontinuation from hospice services. This was evident for 1 (Resident # 30) of 47 residents reviewed during the facility's recertification/complaint survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be completed to ensure each resident receives the care they need. A Significant Change in Status Assessment (SCSA) is required when a resident enrolls in a hospice program or a resident receiving hospice services discontinues those services. On 4/24/25 at 10:01 AM review of Resident #30's medical record revealed the resident was admitted to the facility in June 2016. On 5/2/25 at 12:02 PM in an interview with the Regional Clinical Services Manager (RCSM #12) she stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records review and interviews during a complaint survey, the facility did not ensure each resident had the right to participate in the development and implementation of their person-centered plan of care, including to participate in the planning process and to request meetings for one resident (Resident # 8) out of three residents reviewed for resident rights. Specifically, the facility did not schedule quarterly case plan conferences to evaluate Resident #8's plan of care and to allow for the resident's representative to participate in plan of care decision making. The findings include: The facility's policy and procedure titled Assessment of Resident: Comprehensive Care Planning Process, (last revised June 2024), read in part that the purpose of the policy is to ensure that the best approaches to provide for the quality of care for each resident were developed, implemented and evaluated and to assure that care planning was performed in a timely manner. Participants in the care planning process were to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a complaint survey the facility failed to ensure the resident environment remained free of accident hazards and adequate supervision was provided to prevent accidents for one resident (Resident #10) out of five residents reviewed for accidents/hazards. Specifically, for Resident #10 the facility failed to ensure the following: new interventions were implemented to prevent accidents after the resident had a fall on 2/3/2022 and sustained a laceration to their head; fall care plan was followed; was not left unattended on their side while they were being changed which resulted in a fall; and the behavioral care plan was followed for staff to not leave plastic items within reach of the resident; this created an environmental hazard due to the resident ' s behavior of eating plastic. The findings include: The facility ' s Fall Prevention/ Management Program and Incident/ Accident Management Policy, last revised June 2005, documented once a resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility staff failed to ensure a resident was administered medication according to parameters (#73). This was evident for 1 out of the 5 residents reviewed for unnecessary medications. The findings include: A review of Resident #73's clinical record on 7/9/21 at 10:38 AM revealed the resident was ordered Humalog 100 units/ml inject 15 units, subcutaneously with meals, and to hold if fingerstick is less than 110. A review of the Resident #73's Medication Administration Records (MAR) for June and July 2021 revealed that the resident had fingersticks below 110 but was administered the medication on these dates and times: 6/3/21 at 6:30 AM, 6/12/21 at 6:30 AM, 6/15/21 at 6:30 AM, 6/29/21 at 6:30 AM, 7/1/21 at 6:30 AM, 7/1/21 at 4:30 PM, 7/8/21 at 4:30 PM, 7/9/21 at 6:30 AM, 7/10/21 at 4:30 PM, and 7/13/21 at 6:30 AM. The Director of Nursing (DON) was interviewed on 7/14/21 at 8:05 AM. She was shown the MAR's and the coding of the MAR was discussed. She said that when staff code a medication administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and review of medical records, it was determined that the facility staff failed to provide showers to the resident as per preference and request. This was found to be evident for 1 (Resident #88) out of the 1 residents reviewed during the survey. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few] to be addressed. The findings include: On 7/8/2021 at 7:18 AM, Resident #88 was asked about his/her choices related to bathing, and questioned if s/he received showers. S/he shook his/her head left to right. Surveyor confirmed with Resident # 88 that s/he meant 'no.' S/he then stated that s/he only gets bed baths. Resident #88 was then asked if s/he would like to receive showers and s/he indicated 'yes.' Review of Resident #88's medical record, on 7/8/2021 at 11:13 AM, revealed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of resident council meeting minutes, residents and staff interview, it was determined that the facility staff failed to give adequate responses to grievances presented by the resident council. This was found evident for 3 of 8 months of resident council meeting minutes and facility responses reviewed during the survey. The findings include: On 7/8/2021 at 1:50 PM, the surveyor interviewed the Activity Director (Staff # 17), who stated that there were no group meetings during the pandemic. However, the residents were given a sheet (Resident Council Precautionary Isolation Questionnaire) for them to submit their concerns/grievances. The first group meeting post pandemic was held on 6/22/2021. On 7/9/2021 at 7:30 AM, a review of the resident council meeting minutes on the resident council Precautionary Isolation Questionnaire form revealed documentation of repeat concerns regarding some in- room phones having a very low volume and clothes returning late from the laundry. The concerns related to the phones was noted on the November 2020 resident council Precautionary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, and staff interview, it was determined that the facility staff failed to ensure that residents who were dependent on staff for activities of daily living (ADL) had their toenails trimmed. This was evident for 2 (#64 and #79) out of 5 residents reviewed for ADL care. The findings are: 1. Observation of Resident #64 on 7/7/21 at 11:22 AM revealed resident to be in bed with both feet exposed. The resident's toenails were elongated, thick, and yellow. Observations were made on 7/12/21 at 1:42 PM, 7/13/21 at 11:20 AM, and 7/14/21 at 2:13 PM, and the toenails were elongated, thick, and yellow. Resident #64's clinical record was reviewed on 7/14/21 and their last podiatry appointment was documented as 3/3/21. Interviewed the unit manager (Staff #21) was conducted on 7/14/21 at 2:15 PM and she was shown the resident's toenails. She said the podiatrist comes every two months and agreed that the resident's toenails needed to be trimmed. This surveyor interviewed the regional clinical services manager (Staff #4) on 7/15/21 at 8:18 AM. He was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff, it was determined that the facility failed to have a consistent process in place to ensure that the computer and the physician orders consistently referred to the correct Maryland Order of Life Sustaining Treatments (MOLST). This was evident for 3 of 4 residents (#25, #69 and #38) reviewed during the initial review of residents during the annual survey. The findings include: MOLST (Maryland Medical Orders for Life-Sustaining Treatment) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options. 1. Review of the medical record for Resident #25 on [DATE] at 9:44 AM revealed a notation in the electronic health record (EHR) under the resident's picture, date of birth and allergies noted: 'See MOLST dated [DATE].' However, according to the physician orders, it states 'See MOLST' dated [DATE]. A review of Resident #25's paper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that te facility staff failed to ensure that the information used to complete the Minimum Data Set (MDS) comprehensive assessments was accurate for: 1) Health Conditions regarding falls for Resident #72; 2) Active Diagnoses for Resident who had dementia and falls; #72; 3) Behaviors for Resident #129, 4. resident # 80 for dental services and 5. resident # 34 who was receiving hospice services. This was evident for 4 (#72, #129, #80, #34) of 38 residents reviewed for MDS accuracy during this licensure survey. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few] to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview with staff, it was determined that the facility failed to have an interdisciplinary care plan meeting involving the resident and or the resident's family member for more than six months (resident # 41). The facility also failed to update a care plan, based on a comprehensive assessment that addressed: 2. the risk for dehydration for Resident #56; 3.the risk for choking for Resident #56; and 4. the risk for falls for Resident #56. This was found to be evident for 2 (#41, #56) out of 5 residents reviewed for care planning during the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive understanding. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. 1. The facility failed to update Resident #56's care plans to include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to ensure that residents did not receive unnecessary medications as evidenced by: a significant medication error resulting in the resident #41 receiving duplicate therapy for high cholesterol for more than 3 months, despite multiple reviews by the physician and the pharmacist during this time frame; and the failure to ensure that as needed medication for resident # 25 were only administered when there was indication for their use as evidenced by the administration of a narcotic pain medication without any documentation of a pain assessment. The facility also failed to clearly identify target symptoms for the administration of medications and establish a plan for the ongoing monitoring of those symptoms for Resident #102. This was evident for 3 of 38 residents selected for review during the annual survey process. The findings include: 1. On 8/11/18, review of Resident #41's medical record revealed that the resident resided at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, it was determined that the facility failed to ensure that temperatures of food were monitored prior serving to the residents. This was found to be evident for 17 out of 105 meals reviewed and had the potential to affect any resident who consumes food produced by the kitchen. The findings include: On 8/8/18, review of the HACCP [Hazard Analysis Critical Control Point] Temperature Record for the meals prepared by the facility kitchen for 7/2 thru 8/5 failed to reveal any documented temperatures for 13 suppers; 2 lunches and 2 breakfasts. On 8/8/18 at 11:30 AM, the surveyor reviewed the concern with the Certified Dietary Manager (CDM)regarding the failure to ensure that temperatures are monitored prior to meal service as evidenced by missing temperature recordings on multiple meals every week for past month. The CDM reported that she does review the temperature log, but provided no evidence that this issue had been identified or addressed at this time. On 8/14/18, the CDM reported she has initiated an action plan regarding the concern…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility documentation and interviews with the facility staff, it was determined that the facility failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address deficiencies from a previous survey. This was evident during the investigative stage of the survey and a review of the Quality Assurance Program. The findings include: Review of the Quality Assurance Program with the Assistant Director of Nursing on 8/14/18 at 12:15 PM revealed that effective processes were not put in place regarding repeat deficiencies related to providing medication for residents along with accuracy of medical record documentation as these areas of concern were evident during the investigative stage of the survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and interviews with staff, residents and family, it was determined the facility failed to ensure that residents and their interested family members were provided a quarterly statement of their personal funds account. This was evident for 2 out of 38 residents (# 27; # 116) reviewed during the survey process. The findings include: An interview with Resident's #27 and his/her surrogate (family member) on 8/13/18 at 10:30 AM revealed that a quarterly statement of Resident #27's personal funds account had not been provided since his/her admission on [DATE]. The medical record for Resident #27 identifies him/her as his/her own Financial Responsible Party. An interview with Resident's #116 and his/her surrogate (family member) on 8/13/18 at 12:25 PM revealed that a quarterly statement of Resident #116's personal funds account had not been provided since his/her admission on [DATE]. The medical record for Resident #116 identifies him/her as his/her own Financial Responsible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to ensure two physicians deemed cardiopulmonary resuscitation (CPR) as medically ineffective prior to writing a No CPR order for a resident who did not have an advance directive. This was found to be evident for one out of the 31 residents reviewed during the initial pool process (Resident #179). The findings include: On [DATE], review of Resident # 179's medical record revealed that the resident had resided at the facility for more than a year. Review of the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) revealed the physician had discussed these orders with the patient's surrogate as per the authority granted by the Health Care Decisions Act. These orders included: No CPR, Option B Palliative and Supportive Care. The orders were dated [DATE]. Per the state Health Care Decisions Act: a patient's attending physician may withhold or withdraw as medically ineffective a treatment that, under generally accepted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, it was determined that the facility failed to have a system in place to ensure that resident # 41 and resident #129 and the resident's representatives were provided with written notification of a transfer and the reasons for the move. This was found to be evident for 2 (#41, #129) out of the 38 residents reviewed for hospitalization during the survey and has the potential to affect any resident discharged to the hospital. (Resident #41). The findings include: 1 Review of Resident #41's medical record revealed that the resident had been discharged to the hospital in June 2018 and again in July 2018. Further review of the medical record failed to reveal documentation that the resident or the responsible family member had been provided written notification of the transfer and the reason for the move. On 8/10/18 at 3:52 PM, the corporate nurse confirmed that there was no process in place to provide a written notice of the reason for the transfer. 2. Review of the medical record for Resident # 129 was conducted on 8/13/18 at 5:52 PM. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview with staff, it was determined that the facility failed to submit required Minimum Data Set assessment data for one out of the five residents selected for Resident Assessment review during the survey (Resident #2). The findings include: The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure that each resident receives the care they need. On 8/9/18, review of Resident #2's medical record revealed that a 14 day MDS was submitted for 3/4/18. No further MDS assessments were found after the 3/4/18 MDS. Further review of the medical record revealed that the resident had been discharged from the facility prior to the survey, however, no discharge MDS was found. On 8/10/18 at 1:44 PM, the concern regarding the lack of MDS assessments was addressed with MDS nurse #30 and #31. On 8/10/18 at 3:00 PM, MDS nurse #30 confirmed that there had been no follow up MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical records and staff interviews, it was determined that the facility failed to have a care plan in place for resident # 75 who was prescribed a diuretic for edema and resident # 44 who received psychotropics for Bipolar and Schizophrenia. This was evident for 2 (#75, #44) out of 2 records reviewed. The findings include: 1. A chart review was done for resident # 75 on 8/9/18 at 1:39 PM. Resident was ordered Lasix 40 mg 1 time a day for edema of bilateral lower legs. There was no care plan found on chart for the use of lasix. 2 .Resident # 44 had a history of Bipolar and Schizophrenia with visual hallucinations. Resident was receiving zyprexia 10 mg 1 time per day, Trazadone 50 mg per day for insomnia and olanzapine 10 mg. There was no care plan on the chart at the time of review. A care was added on 8/10/18 after surveyor intervention. The Director of Nursing (DON) and Regional director of Nursing was made aware.

Based on medical record review ,the facility failed to have a comprehensive care plan for resident # 44 diagnosed with Bipolar and Schizophrenia and prescribed psychotropic medication for treatment, resident # 117 prescribed an anticoagulant for treatment of cardiovascular disease, and resident # 75 who was prescribed a diuretic for edema. This was evident for 3 (#44, 117, #117) out of 49 residents reviewed for care plans. 1. 1. A chart review was done for resident # 75 on 8/9/18 at 1:39 PM. Resident was ordered Lasix 40 mg 1 time a day for edema of bilateral lower legs. There was no care plan found on chart addressing the use of lasix. 2 . A resident record review, completed on 8/9/18, revealed that resident # 44 had a history of Bipolar and Schizophrenia with visual hallucinations. Resident is currently receiving Zyprexia 10 mg 1 time per day, Trazadone 50 mg 1 time per day for insomnia and Olanzapine 10 mg 1 time per day. There was no care plan on the chart at the time of review. (A care was added on 8/10/18 after surveyor intervention.) The Director of Nursing (DON) and Regional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, it was determined that the facility failed to complete a post-discharge plan that evidenced participation by the resident's (Resident #131) representative and included post-discharge medical services and contact information for the resident's representative. This was evident for 1 (#131) of 3 residents reviewed for discharge during this annual survey. The findings included: Medical record review revealed that Resident #131 was admitted to the facility with diagnoses that included, but were not limited to, Cerebrovascular Accident, Dementia and Hypercalcemia. Review of the 14-day PPS assessment dated , 6/2/18, revealed that the facility staff entered a score of 5 out of 15 in Section C Cognitive Patterns. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive understanding. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. The Minimum Data Set (MDS) is a comprehensive assessment of the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on administrative and medical record review and staff interview, it was determined that the facility 1. failed to follow a medical consultant's recommendation to discontinue an order for Vitamin D or document a rationale for not following the recommendation for Resident #131. 2. The facility also failed to ensure that a follow up appointment was scheduled for resident #41 following discharge from the hospital after a heart attack. 3. Resident # 105 received ensure clear. The facility failed to record the amount taken in by the resident. This was evident for 3 out of 3 residents reviewed for quality care during the annual survey. The findings include: On 8/11/18, review of Resident #41's medical record revealed that the resident resided at the facility for several years. The resident's diagnosis included heart disease and had been seen by a cardiologist on 1/2/18 with a follow up scheduled for 7/5/18. Further review of the medical record failed to reveal documentation that the resident attended or refused…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, and staff interview, it was determined that the facility staff failed to provide treatment and services for the care of a pressure ulcer consistent with professional standards of practice. Staff failed to follow facility policy for Handwashing and Clean Dressing Change for 1 (#102) of 38 residents reviewed during the survey process. The findings include: Professional standard of practice for a Clean technique dressing change include proper hand hygiene and glove use cleansing hands between each glove change; Maintaining a clean environment by: preparing a clean field, use of clean instruments, and preventing direct contamination of materials and supplies. On 8/10/18 at 10:20 AM, surveyor observed wound care for Resident #102's sacral pressure ulcer completed by LPN (Licensed Practical Nurse) staff #1 assisted by GNA (Geriatric Nursing Assistant) staff #2. Staff #1 opened the residents incontinent brief which revealed that resident had been incontinent of loose stool. Using the brief, Staff #1 pushed the stool down from the back toward the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, and staff interviews, it was determined that facility staff failed to provide appropriate care and services for a resident with an indwelling urinary catheter. This was true for 1 of 38 (#102) residents reviewed during the survey process. Findings include: On 8/10/18 at 10:20 AM, surveyor observed wound care for Resident #102's sacral pressure ulcer completed by LPN (Licensed Practical Nurse) staff #1 assisted by GNA (Geriatric Nursing Assistant) staff #2. Staff #1 opened residents incontinent brief which revealed resident had been incontinent of loose stool. Using the brief, Staff #1 pushed the stool down from the back toward the groin area and did not thoroughly clean Resident #102 prior to providing wound care allowing the loose stool to remain around the foley catheter. A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. After completing the wound care, Staff #1 then got a wash basin and wash cloth, removed the soiled outer dressing, cleansed Resident #102's rectal area and around Resident 102's urinary catheter from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of employee files and interview, it was determined that the facility failed to have an effective system in place to ensure geriatric nursing assistants (GNA) and nurses demonstrated skills competency prior to being scheduled to work independently with residents. This was found to be evident for three out of three GNAs (#40 , #41 and #42) and three out of three nurses ( #43, #44 and #45) hired since December 2017 and reviewed during the sufficient and competent nurse staffing review. The findings include: On 8/13/18, review of employee files for GNAs #40 revealed a start date in March 2018. Review of GNA #41 had a start date in April 2018. GNA #42 had a start date in July and was noted to be on the schedule for 8/10/18. Further review of these GNA's employee files failed to reveal any documentation of a skills assessment having been completed during their orientation in the facility with actual residents. On 8/14/18 at approximately 10:00 AM, the corporate nurse confirmed that the expectation is that GNAs demonstrate competency with caring for residents prior to being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of employee files and interview with staff, it was determined that the facility failed to ensure that geriatric nursing assistants (GNA) received annual performance evaluations. This was found to be evident for three out of thee GNAs (#37, #38, and #39) who have worked for the facility for more than a year and were sampled as part of the staffing review during the investigative portion of the survey. The findings include: Review of GNA #37's employee file revealed a start date in April 2017. Review of GNA #38's file revealed a start date in July 2016. Review of GNA #39's file revealed a start date in July 2016. Further review of these GNA's employee files failed to reveal any annual performance evaluation having been completed in the past 12 months. On 8/13/18 at 4:30 PM, the corporate nurse confirmed there had been no annual evaluation for 3 out of the 3 GNAs reviewed. The concern regarding failure to complete annual evaluations was addressed with the Administrator and Director of Nursing at time of exit on 8/14/18.

Based on medical record review, and interview with staff, the facility failed to obtain a psychological consult for resident # 44. This was for 1 out of 43 records reviewed. Findings include: On 8/9/18 at 9:11 AM during record review, resident # 44 was found to have a diagnosis of Bipolar and Schizophrenia with visual hallucinations. Resident was taking Zyprexia 10 mg 1 tab per day for Bipolar. On the primary Doctors note, dated 7/14/18, under assessment plan # 3, he wrote Bipolar Disorder with physiological follow up. Doctor never wrote an order for this follow up to be done on an order sheet. The behavior sheet provided by the pharmacy, listed Trazadone tab 50 mg and Olanzapine 10 mg, however, there were no targeted behaviors listed for Zyprexia, or Olanzapine and Trazadone was listed for insomnia. Resident was sent out to the hospital on 8/10/18 AM for a change in mental status. Resident was combative with care. Dr. was notified and ordered a urinalysis, culture and sensitivity via a straight catheter. Resident refused and she was sent to the hospital for further evaluation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interviews, it was determined that the pharmacist failed to identify a significant medication error as evidenced by a resident receiving Pravastatin 40 mg in addition to Atoravastin 40 mg for more than 3 months despite no actual order for the Pravastatin. This was found to be evident for one out of 8 residents (Resident #41) reviewed for unnecessary medications during the investigative portion of the survey. The findings include: 1) On 8/11/18, review of Resident #41's medical record revealed that the resident resided at the facility for several years. The resident diagnoses included heart disease and high cholesterol (aka hyperlipidemia). Hyperlipidemia is often treated with a class of drugs known as statins. There are several different statin medications on the market. Atorvastatin, Pravastatin and Lovastatin are three different medications but can all be used to treat hyperlipidemia. Review of the physician orders and the Medication Administration Records (MAR) revealed an order, originally written on 12/17/18, for Atorvastatin (aka Lipitor) 40…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation of medicine carts, on [DATE] at 12:14 PM , it was determined that the facility failed to label eye drops and nasal sprays with dates when opened and expired. There were also eye drops that should have been refrigerated that were not stored in the refrigerator. This was evident for 27 meds out of 37 meds in 7 out of 15 medication carts reviewed. 2. The facility also failed to ensure that narcotic medication removed from resident's supply was administered to resident # 25 This was evident for 1 (#25) resident out of 43 residents. The findings include: 1. On [DATE] at 12:14 PM, 2 med rooms and 7 medicine carts were checked for compliance. The terrace front hall medicine cart had 5 out of 6 eye drops not labeled with date and 3 out of 3 nasal sprays not labeled with dates. One eye drop was not refrigerated. Unit Manager made aware. Terrace front hall had Humalog insulin with no date. This was 1 out of 1 med. Unit Manager notified of findings. Park Front Hall had had 6 out of 9 eye drops not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, it was determined that the facility staff failed to document accurate MDS assessments for Resident (#80) and appropriately assess the need for a dental evaluation. This was evident for 1 (#80) of 38 residents selected for review during the survey process. Findings include: The MDS is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure that each resident receives the care they need. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use, Treatments and procedures. At the end of the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview, it was determined that the facility staff failed to provide safe and sanitary conditions to prevent the development and transmission of disease and infection by failing to carry out a sanitary dressing change (which includes handwashing, and failed to store clean washcloths in a sanitary manner. This was evident for 1 (#102) of 38 residents reviewed during the survey process. The findings include: 1. Professional standard of practice for a clean technique dressing change include proper hand hygiene and glove use cleansing hands between each glove change; Maintaining a clean environment by: preparing a clean field, use of clean instruments, and preventing direct contamination of materials and supplies. On 8/10/18 at 10:20 AM, surveyor observed wound care for Resident #102's sacral pressure ulcer completed by LPN staff #1 assisted by GNA staff #2. Staff #1 opened the resident's incontinent brief which revealed that the resident had been incontinent of loose stool. Using the brief, Staff #1 pushed the stool down from the back…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.